Variable: Adjudication

Adjudication Information

Description:

This code system includes a selection of Adjudication Value Codes which convey the payers assessment of the item provided in the claim under the terms of the patient’s insurance coverage.

Values

This variable is coded, and will contain one of the following values.

Value	Description
CLM_LINE_NCVRD_CHRG_AMT	Non-Covered Charge Amount
CLM_LINE_ALOWD_CHRG_AMT	Line Allowed Charge Amount
CLM_LINE_SBMT_CHRG_AMT	Line Submitted Charge Amount
CLM_LINE_PRVDR_PMT_AMT	Line Provider Payment Amount
CLM_LINE_BENE_PMT_AMT	Line Paid By Beneficiary Amount
CLM_LINE_BENE_PD_AMT	Payment Amount to Beneficiary
CLM_LINE_CVRD_PD_AMT	Payment Amount
CLM_LINE_BLOOD_DDCTBL_AMT	Blood Deductible Amount
CLM_LINE_MDCR_DDCTBL_AMT	Cash Deductible Amount
CLM_LINE_INSTNL_ADJSTD_AMT	Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount
CLM_LINE_INSTNL_RDCD_AMT	Revenue Center Reduced Coinsurance Amount
CLM_LINE_INSTNL_MSP1_PD_AMT	Revenue Center 1st MSP Paid Amount
CLM_LINE_INSTNL_MSP2_PD_AMT	Revenue Center 2nd MSP Paid Amount
CLM_LINE_INSTNL_RATE_AMT	Revenue Center Rate Amount
CLM_SBMT_CHRG_AMT	Total Charge Amount
CLM_LINE_GRS_ABOVE_THRSHLD_AMT	Gross Drug Cost Above Out Of Pocket Threshold
CLM_LINE_GRS_BLW_THRSHLD_AMT	Gross Drug Cost Below Out Of Pocket Threshold
CLM_LINE_LIS_AMT	Low Income Cost Sharing Subsidy Amount
CLM_LINE_TROOP_TOT_AMT	Other True Out Of Pocket Paid Amount
CLM_LINE_PLRO_AMT	Patient Liability Reduction Other Paid Amount
CLM_RPTD_MFTR_DSCNT_AMT	Gap Discount Amount
CLM_LINE_INGRDNT_CST_AMT	Ingredient Cost Amount
CLM_LINE_SRVC_CST_AMT	Dispensing Fee
CLM_LINE_SLS_TAX_AMT	Sales Tax Amount
CLM_LINE_VCCN_ADMIN_FEE_AMT	Vaccination Administration Fee
CLM_PRVDR_PMT_AMT	Provider Payment Amount
CLM_BENE_PMT_AMT	Paid By Beneficiary Amount
CLM_ALOWD_CHRG_AMT	Allowed Charge Amount
CLM_LINE_MDCR_COINSRNC_AMT	Coinsurance Amount
CLM_MDCR_PRFNL_PRMRY_PYR_AMT	Primary Payer Paid Amount
CLM_BENE_PRMRY_PYR_PD_AMT	Line Primary Payer Paid Amount
CLM_LINE_PRFNL_DME_PRICE_AMT	Purchase Price Amount
CLM_LINE_DMERC_SCRN_SVGS_AMT	Screen Savings Amount
CLM_BENE_PD_AMT	Amount Paid To Beneficiary Amount
CLM_OPRTNL_DSPRTNT_AMT	Operating Disproportionate Share Amount
CLM_OPRTNL_IME_AMT	Operating Indirect Medical Education Amount
CLM_BLOOD_LBLTY_AMT	Beneficiary Blood Deductible Liability Amount
CLM_MDCR_DDCTBL_AMT	Beneficiary Deductible Amount
CLM_NCVRD_CHRG_AMT	Inpatient(or other Part A) Non-covered Charge Amount
CLM_MDCR_COINSRNC_AMT	Beneficiary Coinsurance Liability Amount
CLM_MDCR_IP_LRD_USE_CNT	Beneficiary Medicare Lifetime Reserve Days (LRD) Used Count
CLM_INSTNL_MDCR_COINS_DAY_CNT	Beneficiary Total Coinsurance Days Count
CLM_INSTNL_NCVRD_DAY_CNT	Claim Medicare Non Utilization Days Count
CLM_INSTNL_PER_DIEM_AMT	Claim Pass Thru Per Diem Amount
CLM_INSTNL_CVRD_DAY_CNT	Claim Medicare Utilization Day Count
CLM_MDCR_IP_PPS_DSPRPRTNT_AMT	Claim PPS Capital Disproportionate Share Amount
CLM_MDCR_IP_PPS_EXCPTN_AMT	Claim PPS Capital Exception Amount
CLM_MDCR_IP_PPS_CPTL_FSP_AMT	Claim PPS Capital Federal Specific Portion (FSP) Amount
CLM_MDCR_IP_PPS_CPTL_IME_AMT	Claim PPS Capital Indirect Medical Education (IME) Amount
CLM_MDCR_IP_PPS_OUTLIER_AMT	Claim PPS Capital Outlier Amount
CLM_MDCR_IP_PPS_CPTL_HRMLS_AMT	Claim PPS Old Capital Hold Harmless Amount
CLM_MDCR_IP_PPS_CPTL_TOT_AMT	Claim Total PPS Capital Amount
CLM_MDCR_INSTNL_PRMRY_PYR_AMT	Primary Payer (if not Medicare) Claim Paid Amount
CLM_INSTNL_PRFNL_AMT	Professional Component Charge Amount
CLM_INSTNL_DRG_OUTLIER_AMT	DRG Outlier Approved Payment Amount
CLM_MDCR_IP_BENE_DDCTBL_AMT	Beneficiary Inpatient (or other Part A) Deductible Amount
CLM_HIPPS_UNCOMPD_CARE_AMT	Claim Uncompensated Care Payment Amount
CLM_MDCR_INSTNL_BENE_PD_AMT	Institutional Paid to Beneficiary Amount
CLM_MDCR_HOSPC_PRD_CNT	Hospice Period Count
CLM_MDCR_HHA_TOT_VISIT_CNT	Claim HHA Visit Count
CLM_MDCR_IP_PPS_DRG_WT_NUM	PPS DRG Weight Number
CLM_BENE_INTRST_PD_AMT	Beneficiary Interest Paid Amount
CLM_BENE_PMT_COINSRNC_AMT	Beneficiary Coinsurance Amount
CLM_BLOOD_CHRG_AMT	Blood Charge Amount
CLM_BLOOD_NCVRD_CHRG_AMT	Blood Noncovered Charge Amount
CLM_COB_PTNT_RESP_AMT	Coordination of Benefits Patient Responsibility Amount
CLM_OTHR_TP_PD_AMT	Other Third Party Payer Paid Amount
CLM_PRVDR_INTRST_PD_AMT	Provider Interest Paid Amount
CLM_PRVDR_OTAF_AMT	Provider Obligation To Accept as Full Amount
CLM_PRVDR_RMNG_DUE_AMT	Remaining Amount to Provider
CLM_TOT_CNTRCTL_AMT	Total Contractual Amount Discrepancy
CLM_FINL_STDZD_PYMT_AMT	Standardized Payment Amount
CLM_HAC_RDCTN_PYMT_AMT	Hospital Acquired Condition Reduction Amount
CLM_HIPPS_MODEL_BNDLD_PMT_AMT	Blended Payment Amount
CLM_HIPPS_READMSN_RDCTN_AMT	Readmission Reduction Amount
CLM_HIPPS_VBP_AMT	HIPPS Value Based Purchasing Amount
CLM_INSTNL_LOW_VOL_PMT_AMT	Low Volume Payment Amount
CLM_MDCR_IP_1ST_YR_RATE_AMT	First Year Rate Amount
CLM_MDCR_IP_SCND_YR_RATE_AMT	Second Year Rate Amount
CLM_PPS_MD_WVR_STDZD_VAL_AMT	Maryland Waiver Standardized Amount
CLM_SITE_NTRL_CST_BSD_PYMT_AMT	Site-Neutral Cost-Based Payment Amount
CLM_SITE_NTRL_IP_PPS_PYMT_AMT	Site-Neutral IPPS Payment Amount
CLM_SS_OUTLIER_STD_PYMT_AMT	Short Stay Outlier Payment Amount
CLM_PRVDR_ACNT_RCVBL_OFST_AMT	Provider Offset Amount
CLM_LINE_NCVRD_PD_AMT	Amount Paid for Noncovered Product or Service
CLM_LINE_OTAF_AMT	Provider Obligation To Accept as Full Amount
CLM_LINE_OTHR_TP_PD_AMT	Other Third Party Paid Amount
CLM_LINE_ADD_ON_PYMT_AMT	Add On Payment Amount
CLM_LINE_NON_EHR_RDCTN_AMT	Non-EHR Reduction Amount
CLM_REV_CNTR_TDAPA_AMT	Transitional Drug Add-On Payment Adjustment
CLM_LINE_CARR_CLNCL_CHRG_AMT	Carrier Clinical Charge Amount
CLM_LINE_CARR_PSYCH_OT_LMT_AMT	Therapy Amount Applied to Limit
CLM_LINE_PRFNL_INTRST_AMT	Professional Interest Amount
CLM_MDCR_PRMRY_PYR_ALOWD_AMT	Line Primary Payer Allowed Amount
CLM_CMS_CALCD_MFTR_DSCNT_AMT	CMS Calculated Manufacturer Discount Amount
CLM_LINE_REBT_PASSTHRU_POS_AMT	Rebate Passthrough POS Amount
CLM_PHRMCY_PRICE_DSCNT_AT_POS_AMT	Pharmacy price discount
CLM_LINE_GRS_CVRD_CST_TOT_AMT	Claim Line Gross Covered Cost Amount
CLM_LINE_RPTD_GAP_DSCNT_AMT	Claim Line Reported Gap Discount Amount
TOT_RX_CST_AMT	Total RX Cost Amount